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health centers, and health maintenance organizations.4 All of these new organizational forms offer two or more services which have been traditionally givenĀ ...
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Human Service Ideology

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FRANK BAKER, PhD

A discussion of the new orientation of mental health professionals toward human services is presented.

Introduction Human service ideology appears to be developing among mental health professionals and other community caregivers as a new belief system which may have the profound impact for the 1970s that community mental health ideology had for the previous decade. During the 1960s, mental health professionals expanded the scope of their activities and perspectives from the relatively insular mental hospital or clinic to the more inclusive community mental health program. During the 1970s, mental health professionals appear to be challenged to evolve the scope of their activities and perspectives even further by designing extensive human service systems which are organized to bring together a wide variety of human resources in the provision of comprehensive integrated assistance to clients. During the 1960s, observers of the contemporary mental health scene witnessed the growth and development of a widely heralded innovative community-oriented conceptual approach in mental health. Beginning with a few scattered individuals in a variety of professional fields alerting their colleagues to the advent of a new era, the community mental health movement and its ideology came to dominate mental health theory and practice during the past decade.' While it is undoubtedly true that many mental health professionals still have not assimilated the intellectual, let alone the functional, implications of community mental health theory and practice, a new belief system is beginning to develop which asks mental health Dr. Baker is from the Laboratory of Community Psychiatry, Harvard Medical School, Boston, Massachusetts. Preparation of this paper was supported by National Institute of Mental Health Grant MH 18382. 576 AJPH JUNE, 1974, Vol. 64, No. 6

professionals to expand their conceptual horizons even further and to consider their professional roles within a still broader context of human service systems.24

Evolution of Mental Health Beliefs Before examining the evidence supporting the major thesis of this paper that a human service orientation is developing as a new major ideology, first a definition of ideology will be offered and then a brief review of earlier developments in mental health beliefs will be presented. Ideology may be defined as a commonly adhered-to system of ideas or beliefs which serves to justify the position of a group and as a rationale for its behavior. By defining ideology as a system, emphasis is placed upon the fact that there is a set of interrelated beliefs which may or may not be organized in a logical manner. The concept of a belief system as a basis for self-definition and as a guide to behavior can be useful for understanding social groups, complex organizations, and the individual. The attitudes of caregivers have long been recognized as crucial variables affecting the type and quality of helping services offered to clients. Attitudes and beliefs are a particularly important aspect in areas where there is little agreement on scientific evidence which can serve as a basis for informed opinion. Mental health and other human service disciplines have proceeded to develop new programs more often on the basis of belief than on hard technical evidence. Faced with a variety of social and professional forces for change, those charged with the design and development of professional caregiving systems are likely to proceed on the basis of ideology in the absence of a sufficient supply of other criteria.

As mental health programs developed during the last two decades, a number of studies were made of the ideologies that mental health professionals utilize in explaining and treating mental illness. The rebirth of humanism during the 1950s resulted in a redefinition of the mental hospital as a community" of persons rather than a rigid institution of incarceration. The Custodial Mental Illness (CMI) Scale was developed by Gilbert and Levinsons to measure custodialism and humanism as ideological orientations in the mental hospital. Gilbert and Levinson found that those hospital units having the most custodial policy consisted of staff members with the most custodial ideologies and the most authoritarian personalities. An examination of therapeutic ideologies among psychiatric residents and senior medical staff undertaken by Sharaf and Levinson6 focused on the bipolar dimensions of a "psychotherapeutic" versus "sociotherapeutic" treatment orientation. In their study of psychiatric services to New Haven residents, Hollingshead and Redlich7 similarly defined their practitioners as adhering to either of two orientations: directive-organic or analytic-psychotherapeutic. The attempt to clarify the ideological orientations of mental health workers was advanced by Strauss et al.8 when they integrated the somatic dimension refined by Hollingshead and Redlich with the psychotherapeutic and sociotherapeutic dimension measures identified by Sharaf and Levinson. Although Strauss et al. hypothesized that each of these orientations represented a separate and distinct ideology, their data indicated that only the sociotherapeutic dimension was an independent one. The somatotherapeutic and psychotherapeutic orientations were strongly negatively correlated, suggesting the existence of a continuum of "psycho" versus "somato" ideology. Using data from a nationwide survey of hospital psychiatrists, Armor and Klerman9 found factor analytic support for the independent ideologies of somatotherapy and psychotherapy. Since only a small amount of the variance could be explained by each factor, these researchers saw the need to refine their instruments and predicted that sociotherapy might develop into full ideological status under the aegis of

community psychiatry. In the second half of the past decade, Baker and a growing collectivity of mental health professionals were formning a new social movement in mental health and beginning to share a common community mental health ideology. Baker and Schulberg described this new ideological movement in the mental health field as particularly concerned with such issues as: professionals assuming responsibility for an entire population rather than an individual patient only; primary prevention of mental illness through the amelioration of harmful environmental conditions; treating patients with the goal of social rehabilitation rather than personality reorganization; comprehensive continuity of care and concern for the mentally ill; and total involvement of both professional and nonprofessional helpers in caring for the mentally ill. Schulberg and Baker' later described community mental health ideology as the mental health professional

Schulbergl 0 postulated that

"belief system of the 1960s." Through the development of a valid and reliable Community Mental Health Ideology (CMHI) Scale,' 0 it was possible to demonstrate that this new ideological orientation existed as a major belief system among nationwide samples of various professional groups and that degree of commitment to this ideology was significantly higher among those individuals who had received additional training in this specialty. Evidence of highly satisfactory reliability and validity were obtained in the first study and in subsequent research.' 1,1 2 Gross' 3 found that mental health workers with high CMHI Scale scores were more likely to make the behavioral choice of working in a community setting than those with low scale scores. In a nationwide study of graduate students in psychiatric nursing, it was found that commitment to community mental health ideology related to an acceptance of broader community-oriented role functions for the psychiatric nurse.' 4 Community mental health ideology has not only been empirically related to expanding roles for mental health professionals but has been associated with liberal versus conservative value changes in the mental health professions and the larger society. For example, Baker and Schulberg' 5 found that strong community mental health attitudes are significantly correlated, in a negative direction, with dogmatism and political-economic conservatism. Hersch ' 6 has related the community mental health movement and its underlying ideology to social-historical changes in the United States. He asserts that it is not accidental that the community mental health movement reached its fruition in this country during the decade of the 1960s, a period which was characterized by a spirit of social-political reform and an emphasis on a "revitalized humanistic concern for the disadvantaged, the oppressed and the powerless."

Evidence of a New Ideology In recent unpublished research with the CMHI Scale, the author has, after interviewing respondents, concluded that the CMHI Scale does not by itself cover some major attitude dimensions which are currently developing among mental health professionals. This experience has led to the major thesis of this paper that new beliefs are evolving which have coherence as a human service ideology. A human service orientation is not seen as incompatible with an acceptance of community mental health concepts but rather as going beyond these ideas as the result of a natural evolutionary process. It would be expected that just as those who endorse a sociotherapeutic ideological orientation would also endorse a community mental health orientation,' 7 many of these same people would also support a human service ideology, although each of these successive ideological positions incorporates even broader concepts of appropriate professional practice. In examining the growth of a human service orientation, it is important to recognize the relationship between change and concepts. It is often the case that change occurs first and then is followed by conceptual efforts which COMMUNITY MENTAL HEALTH

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attempt to rationalize the activity, but it is also true that modification of belief is an important precursor to action. A trend toward comprehensiveness and coordination of the many services traditionally supplied by separate disciplines or agencies can be observed. Comprehensiveness is a major goal in the growth of such organizations as community mental health centers, multiservice centers, neighborhood service centers, youth opportunity centers, neighborhood health centers, and health maintenance organizations.4 All of these new organizational forms offer two or more services which have been traditionally given independently of one another. March1 8 concluded that such programs seek to provide comprehensive and coordinated assistance to clients by incorporating the following features: comprehensiveness of services; decentralization of services into areas of high need; concerting of resources from different programs; co-location of service components; and operational integration of services in proper sequence thereby eliminating present duplication and wasted time for clients and employees. The movement toward comprehensiveness and coordination of services is also apparent in the actions of many state governments to combine several separate health and social service programs within one new department. O'Donnell' 9 notes that approximately 20 states have already combined several services and many other states are seriously considering similar reorganizations. In Massachusetts, for example, the new Executive Office of Human Services combines the traditionally separate public health, mental health, and social welfare programs of the state under one administrative control. At the federal level, service integration legislation has been under development at the Department of Health, Education, and Welfare which would enable and encourage states and localities to unify the various programs and resources available to provide human services in order to facilitate the improved delivery and utilization of those services and increase their effectiveness in improving the lives of individuals and their families.20 The legislation would encourage, assist, and support state and local agencies in reorganizing, reassigning functions, and entering into new cooperative arrangements at different levels in the system of delivery of services in order to meet human needs and alleviate or renmove conditions of dependency as well as to improve the effective delivery of services. The integration of human services was invited in a bill, the Community Services Act, introduced in the Senate in 1967, at the request of Elliot Richardson, who was then AttorneyGeneral of Massachusetts. While he was Secretary of HEW, Richardson favored the development of legislation to provide integrated services.20 Although the Allied Services Bill proposed in 1972 by HEW did not pass Congress, Secretary Richardson went ahead with funding demonstration projects to test the feasibility of such programs.2' Changes are occurring not only in the ways that services are organized, but also in the way they are thought about. There is an increasing tendency to conceptualize the variety of health and social welfare services in a new way which emphasizes an assumption of the generic quality of 578 AJPH JUNE, 1974, Vol. 64, No. 6

the helping actions of professional and nonprofessional caregivers despite a diversity of training and titles. There is also a growing professional as well as societal recognition of the common denominator inherent in the varied problems presented by clients of helping agencies. There is an increasing tendency to designate a community's variety of health, mental health, and social welfare programs as "human services." This appellation reflects the increasing recognition of the commonalities in problems and services.3 Demone,4 advqcating the development of human services systems, reminds the defender of the status quo that he need only follow a few clients through the present system in order to realize that it is poorly designed to meet the needs of those it purports to serve. Demone writes, "a complex inter- and intraorganizational policy arrangement surfaces with boundaries which are often artiflcial and hamper the delivery of needed assistance. Such terms as fragmentation, overlapping, duplication, gaps in services, and lack of coordination take on concrete meaning for individuals who need services." For example, Demone points out that a working mother may easily enroll her 4-year-old child in a Headstart class but may encounter severe difficulties in obtaining such services for another one of her children who is too young for this special program. Families with multiple problems often are able to receive help for only one of them, because the initial agency to which they tum for help either does not recognize the other problems, or does not refer the family to other appropriate caregiving resources. The growth of human service concepts arises not only of a recognition of basic similarities in problems of living, and generic aspects of the helping activities of various community agencies, but it also comes about through a reaction to the inefficiency, compartmentalization, specialization, bureaucracy, program barriers, and service gaps which an increasing number of professionals assert characterize the existing public governmental service system. This criticism of existing service systems is used to justify a move toward alternative human service models, and the impetus of many of the new programs which are being proposed clearly appears to be a reaction to the deficiencies of traditional patterns of organizing community resources and services. The current movement toward human services appears to be developing its own unique belief system which has characteristics which distinguish it from earlier ideological orientations which have played a major role in organizing and mobilizing mental health professionals.

Themes in Human Service Ideology Although the human service ideological structure is still undergoing refinement and development, five general themes can be identified as characterizing this belief system. These themes are: systemic integration of services; comprehensiveness and accessibility; client troubles defined as problems in living; generic characteristics of helping activities; and accountability of service providers to clients.

Systemic Integration of Services A major theme in this new ideology is a belief that genuinely effective, comprehensive services can be provided only through the forging of systemic linkages which bring together the various caregiving agencies needed to provide a complex array of resources, technologies, and skills. Reacting to obvious gaps and fragmentation in service programs in an era of social reform, many are calling for increased integration between the various components of service into systems responsive to the needs of clients rather than primarily the needs of the providers of service. Kahn2 2 observes that "internal needs of a profession, agency, or intervention system do not adequately take into account problems of boundaries and integration between units or intervention systems" (p. 155). Hunter23 urges both specific program representatives and those concerned with social planning to examine any problem with which an agency is dealing in terms of all its aspects, "noting all of the systemic elements impinging on it," and he strongly suggests that "it is incumbent upon social welfarists to think more in terms of human development systems in contrast to disparate elements such as casework, settlement house, relief check, homemaker, employment office, legal aid bureau or what have you."23 Auerswald,24 a psychiatrist who has been "involved in designing and implementing a neighborhood health services system for provision of comprehensive biopsychosocial care to a so-called disadvantaged community," asserts that in order to avoid the current fragmentation of service delivery it is necessary to design and implement new integrated systems of service delivery. He further points to the need for developing systemically integrated services for a target community which adequately takes into account the total ecological systems in which a person and his problems are embedded. Considerable attention has been paid in recent years to the importance of relations between and among community organizations and an increasing number of publications dealing with interorganizational relations, particularly in the health and welfare field, have appeared.25 In recognition of the importance of systemic interdependence in planning and operating comprehensive human service programs, systems concepts are being applied in defining the problems of management, organization-environment interaction, and interorganizational relations.2 6

Comprehensiveness and Accessibility A theme related to integrating services in a total system of care is the concern that such services be comprehensively accessible. Where system linkages between service programs are weak or nonexistent, people are left to fill in the gaps between programs. Even where there is a relatively full range of services available, linked in some operational pattern, the full range of services may not be available to individuals or families because of barriers related to travel time, waiting time, and cost of care. Comprehensiveness and accessibility were goals in establishment of community mental health centers and a

few centers have established constructive operational roles in a network of human services. However, some centers have had problems with their medical staffs in learning to work effectively with nonmedical service units. Also the "center" concept has been interpreted too frequently as meaning that all relevant services should be incorporated within a single complex organizational entity. Demone4 has suggested that a network model may be more appropriate. He describes the "human service network" model as focusing on building linkages between existing and planned organizations so as to facilitate client services rather than seeking to incorporate all relevant services within a single agency. In this model the basic needs of a population are determined along with what services are essential for meeting them and then a consortium of agencies divides responsibilities according to particular expertise with attention being given to making these services accessible to clients where they live and work. Other alternative structures which are arising at the community level with comprehensiveness and accessibility as prominent goals include multiservice centers, diagnostic centers, and information and referral centers. Basic assumptions in this aspect of human service ideology include the idea that effective community action for troubled individuals requires continuity of concern for the person in his involvements with society regardless of awkward jurisdictional boundaries and that many people are hardly being touched by our current best efforts to reach them. Basic to this concern is the definition of the locus of client problems which is another major theme in the developing human service ideology. Client Trouble Defined as Problems in Living Ryan2 7 has identified two contrasting generic aspects of ideological approaches to the analysis and solution of social problems. In what he calls the "exceptionalist" viewpoint, the problem is seen as located within the individual. Hersch' 6 has called this the "clinical ideology" and observes that in this orientation the individual is identified as deviant from some norm of health and this deviance is viewed as abnonnal. As Hersch describes it, "the abnonnality has the character of a disease and is regarded as part of, or inside of, the person" (p. 750). The abnormality is viewed as a particular type of disease that can be named, classified, and treated. The aim of intervention is to change the person so that his deviant condition is eliminated or so that its consequences are minimized. Ryan2 7 calls this orientation "blaming the victim" and the individual is seen as the locus of the problem and as somehow at fault for the miserable condition. A contrasting orientation which Ryan calls "the universalist viewpoint" views problems as inclusive rather than exclusive, public rather than private, and general rather than special. According to the universalistic viewpoint, social problems are a function of the social arrangements of the community or the society. These social arrangements are seen as the major locus of problems and rather than focusing only on the causalities of damaging COMMUNITY MENTAL HEALTH 579

environments the interventionist should also focus on changing the environment. In this new view which may be called the "problems in living" orientation, rather than viewing illness as an entirely intrapsychic process, the focus is on the problems individuals and populations have in coping with difficult environments. This viewpoint asserts that instead of focusing on individual deficiencies, the deficiencies of the social system should be the principal target for intervention. Rather than attaching a diagnostic label and attempting to do remedial repairs to a defective individual, it is assumed that it is more useful to examine an individual's problems in living in order to be helpful to him, that defective social arrangements can be improved and made more equitable, and that problems related to individual-environment fit can be prevented.

Generic Characteristics of Helping Activities

Schulberg3 has commented that the widespread use of the designation of a variety of health and social welfare services as human service organizations "indicates an appreciation for the generic quality integral to the helping actions of professional and nonprofessional care givers" (p. 568). He observes that the traditional designations between the helping functions of the different mental health professionals are increasingly artificial. Iscoe28 has also noted that "painful though it may be, professionals are beginning to recognize that many of the sacred ministrations with regard to human beings can be carried on by relatively less well-trained or even untrained professionals" (p. 26). The development of community mental health centers contributed to the growth of a belief that responsibility should depend upon competence in the job to be done rather than upon the formal training an individual has in a particular professional discipline. In addition, the development of nontraditional community resources to deal with drug dependency and the general growth of such self-help groups in other community problem areas has raised questions about the value of traditional professional jurisdictional privileges. There has been an increased interest in the training of "generalists" as opposed to "specialists" in recognition of the generic aspects of helping roles. For example, an increasing number of junior colleges throughout the United States, in recognition of such generalist roles as well as in response to shortages in traditionally training manpower, are now training human service workers.29 Accountability of Service Providers to Clients A fifth aspect of human service ideology is the belief that the providers of services have a responsibility of being accountable to the users and inquirers for service as well as to the public at large. In recent years there has been extensive discussion of what has been generally termed "social accounting." However, many of these proposals have called for the accounting to be made to centralized 580 AJPH JUNE, 1974, Vol. 64, No. 6

highly trained technologists. Ryan,2 7while recognizing the "importance of centralized social assessment-if only because there is an absolute necessity for an overall national policy and huge national investments in the human services," points out that at such centralized levels the recipients of services are likely to be left out of the process (p. 264). What is new in the developing human service ideology is a belief that programs must make a more direct accounting to the beneficiaries of the services provided. This belief is sometimes expressed as an emphasis on community control and the idea that people must have control over the institutions that affect their lives. Originating in the "maximum feasible participation" concept of the war on poverty, this idea has survived the confusion and ambiguities of the 196Os30,3 1 and has endured as a belief that consumers of service must be involved in the design and monitoring of human service programs. This fifth ideational theme, along with the other four outlined above, requires further examination in terms of its specific content and relationships to other human service ideological components. The author is presently beginning research to empirically define the structure of the human service ideology and to examine the extent and degree of acceptance of this new ideology among a variety of mental health professionals and other community caregivers.

Summary and Conclusion This paper has traced the recent development of ideology among mental health professionals and has concluded that a more inclusive human service belief system is currently developing among mental health and other community caregivers. Growing out of the community mental health ideology which gained prominence in the past decade, the human service orientation is seen as potentially playing a major role in rationalizing and justifying an even more expanded pattern for organizing comprehensive integrated programs of service for the 1970s. References 1. Schulberg, H. and Baker, F. Community Mental Health: Belief System of the 1960's. Psychiatr. Opinion 6:14-26, 1969. 2. Newman, E. and Demone, H. W. Policy Paper: A New Look at Public Planning for Human Services. J. Health Soc. Behav. 10:142-149, 1969. 3. Schulberg, H. C. Challenge of Human Service Programs

for Psychologists. Am. Psychol. 27:566-573, 1972. 4. Demone, H. Human Services at State and Local Levels and the Integration of Mental Health. In American Handbook of Psychiatry, edited by Caplan, G., Vol. 2. Basic Books, New York, 1973. 5. Gilbert, D., and Levinson, D. "Custodialism" and "Humanism" in Staff Ideology. In The Patient and the Mental Hospital, edited by Greenblatt, M., Levinson, D., and Williams, R., pp. 20-36. Free Press, Glencoe, Illinois, 1957.

6. Sharaf, M., and Levinson, D. Patterns of Ideology and Role Differentiation among Psychiatric Residents. In The Patient and the Mental Hospital, edited by Greenblatt, M., Levinson, D., and Williams, R., pp. 263-285. Free Press, Glencoe, Illinois, 1957. 7. Hollingshead, A., and Redlich, F. Social Class and Mental Illness. John Wiley, New York, 1958. 8. Strauss, A., Schatzman, L., Bucher, R., Ehrlich, D., and Sabshen, H. Psychiatric Ideologies and Institutions. Free Press of Glencoe, New York, 1964. 9. Armor, D., and Klerman, G. Psychiatric Treatment Orientations and Professional Ideology. J. Health Soc. Behav. 9:243-255, 1968. 10. Baker, F., and Schulberg, H. C. The Development of a Community Mental Health Ideology Scale. Community Ment. Health J. 3:216-225, 1967. 11. Langston, R. D. Community Mental Health Centers and Community Mental Health Ideology. Community Ment. Health J. 6:387-392, 1970. 12. Breeskin, J. Community Health Ideology in the Military. Presented at the 19th Annual Conference of Air Force Behavior Scientists, January, 1972. 13. Gross, H. W. The Community Mental Health Ideology Scale: Validation. Butler Hospital, Providence, Rhode Island, 1972 (mimeographed). 14. Howard, L. A., and Baker, F. Ideology and Role Function of the Nurse in Community Mental Health. Nurs. Res. 20:450-454, 1971. 15. Baker, F., and Schulberg, H. Community Mental Health Ideology, Dogmatism, and Political-Economic Conservatism. Community Ment. Health J. 5:443-456, 1969. 16. Hersch, C. Social History, Mental Health, and Community Control. Am. Psychol. 27:749-754, 1972. 17. Rabkin, J. G. Opinions about Mental Illness: A review of the Literature. Psychol. Bull. 77:153-171, 1972. 18. March, M. The Neighborhood Center Concept. Public Welfare, 26:97-111, 1968. 19. O'Donnell, E. Organization for State Administered Human Resource Programs in Rhode Island. Report to

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the General Assembly by the Special Legislative Commission to Study Social Services. June, 1969. Washington Report on Medicine and Health, January 10, 1972. Washington Report on Medicine and Health, October 2, 1972. Kahn, A. J. Theory and Practice of Social Planning. Russell Sage, New York, 1969. Hunter, D. Seven Motive Ideas. Public Welfare 23:171-176, 1965. Auerswald, E. H. Interdisciplinary versus Ecological Approach. In General Systems Theory and Psychiatry, edited by Gray, W., Duhl, F. J., and Rizzo, N. E., pp. 373-386. Little Brown, Boston, 1969. National Center for Health Services Research and Development and the Johns Hopkins University. Inter-Organizational Research in Health: Conference Proceedings, January, 1970. Baker, F., and O'Brien, G. Inter-systems Relations and Coordination of Human Service Organizations, Am. J. Public Health 61:130-137, 1971. Ryan, W. Blaming the Victim. Vintage Books, New York, 1972. Iscoe, I. Professional and Subprofessional Training in Community Mental Health as an Aspect of Community Psychology. In Division 27 of the American Psychological Association. Issues in Community Psychology and Preventive Mental Health, pp. 21-31. Behavioral Publications, New York, 1971. Glasscote, R. M., and Gudeman, J. E. The Staff of the Mental Health Center: A Field Study. Joint Information Service of the American Psychiatric Association and the National Association of Mental Health, Washington, D.C., 1969. Moynihan, D. P. Maximum Feasible Misunderstanding: Community Action in the War on Poverty. Free Press, New York, 1969. Rubin, L. B. Maximum Feasible Participation: The Origins, Implications, and Present Status. Ann. Am. Acad. Polit. Soc. Sci. 385:14-29, 1969.

PhD PROGRAM IN EPIDEMIOLOGY The Graduate School of Arts and Sciences of Columbia University, in cooperation with the School of Public Health of the Faculty of Medicine, invites applications for a PhD program in epidemiology for the fall semester, 1974. Students enrolled in the program will have an opportunity to address major health problems of our society from an interdisciplinary research perspective. The program permits specialization according to the student's background and interests in biomedical, social, or statistical epidemiology. Areas of study include the measurement of manifestations of disease and related social and behavioral phenomena, the design of field surveys, procedures for collecting and handling large bodies of data, and statistical analyses. For further information write Dr. Robert Friis, Division of Epidemiology, Columbia University School of Public Health, 600 West 168 St., New York, NY 10032.

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